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Dineen SP. Experience is Key: Considerations of Gastrectomy During CRS/HIPEC for Extensive Pseudomyxoma Peritonei. Ann Surg Oncol 2024:10.1245/s10434-024-16188-7. [PMID: 39289246 DOI: 10.1245/s10434-024-16188-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2024] [Accepted: 08/27/2024] [Indexed: 09/19/2024]
Affiliation(s)
- Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA.
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2
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Fackche NT, Schmocker RK, Nudotor R, Kubi B, Cloyd JM, Grotz TE, Fournier KF, Dineen SP, Veerapong J, Baumgartner JM, Clarke CN, Patel SH, Wilson GC, Lambert LA, Pokrzywa C, Abbott DE, Lee B, Staley CA, Zaidi MY, Johnston FM, Greer JB. Preoperative CA 19-9 Predicts Disease Progression in Colorectal Peritoneal Metastases Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: An Analysis from the US HIPEC Collaborative. Ann Surg Oncol 2024; 31:3314-3324. [PMID: 38310181 DOI: 10.1245/s10434-024-14890-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 01/02/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Patients with colorectal peritoneal metastases (CRPM) are increasingly treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). Unfortunately, data identifying preoperative risk factors for poor oncologic outcomes after this procedure are limited. We aimed to determine the prognostic value of preoperative CEA, CA 125, and CA 19-9 on disease progression after CRS/HIPEC. METHODS Patients with CRPM treated with curative intent CRS/HIPEC from 12 participating sites in the United States from 2000 to 2017 were identified. Progression-free survival (PFS), defined as disease progression or recurrence, was the primary outcome. RESULTS In 279 patients who met inclusion criteria, the rate of disease progression was 63.8%, with a median PFS of 11 months (interquartile range [IQR] 5-20). Elevated CA 19-9 was associated with dismal PFS at 2 years (8.9% elevated vs. 30% not elevated, p < 0.01). In 113 patients who underwent upfront CRS/HIPEC, CA 19-9 emerged as the sole tumor marker independently predictive of worse PFS (hazard ratio [HR] 2.88, p = 0.048). In the subgroup of patients who had received neoadjuvant therapy (NAT), no variable was independently predictive of PFS. CA 19-9 levels over 37 U/ml were highly specific for accelerated disease progression after CRS/HIPEC. Lastly, there was no association between PFS and elevated CEA or CA 125. CONCLUSIONS Elevated CA 19-9 is associated with decreased PFS in patients with CRPM. While traditionally CEA is the main tumor marker assessed in colon cancer, we found that CA 19-9 may better inform preoperative risk stratification for poor oncologic outcomes in patients with CRPM. However, prospective studies are required to confirm this association.
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Affiliation(s)
- Nadege T Fackche
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Ryan K Schmocker
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Nudotor
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Boateng Kubi
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
| | - Keith F Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Callisia N Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Laura A Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Courtney Pokrzywa
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Byrne Lee
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA.
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3
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Zohar N, Nevler A, Esquivel J, Yeo CJ, Benvenisti H, Elbaz N, Assaf D, Mor E, Bowne WB. International Expert Consensus on Defining Textbook Oncologic Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Peritoneal Metastasis. J Am Coll Surg 2024; 238:387-401. [PMID: 38149780 DOI: 10.1097/xcs.0000000000000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Textbook oncologic outcome (TOO) is a composite metric shown to correlate with improved survival after curative intent oncologic procedures. Despite increasing use among disciplines in surgical oncology, no consensus exists for its definition in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). STUDY DESIGN An international consensus-based study employed a Delphi methodology to achieve agreement. Fifty-four senior surgeons from the peritoneal surface malignancies field received a questionnaire comprising TOO parameters divided into 3 surgical domains: operative, short-term, and long-term postoperative outcomes. Two online meetings with participants defined the new criteria. Consensus was achieved when 75% of agreement rate was reached. Clinical data of patients who underwent CRS and HIPEC for colorectal peritoneal metastasis between 2010 and 2022 from 1 designated center (Sheba Medical Center) were collected, the consensus definition applied and outcomes analyzed. RESULTS Thirty-eight surgeons (70%) participated. Expert consensus TOO parameters for colorectal peritoneal metastasis CRS and HIPEC included the absence of unplanned reoperations during 30 days postoperation, absence of severe postoperative complications (Clavien-Dindo ≥III), absence of unplanned readmissions during 30 days postoperation, 90-day postoperative mortality, and absence of contraindications for chemotherapy within 12 weeks from operation, and included the achievement of complete cytoreduction (CC0). The study cohort consisted of 251 patients, and 151 (60%) met TOO criteria. Patients who achieved TOO had significantly better overall survival (median 67.5 months, 95% CI) vs patients who did not achieve TOO (median 44.6 months, 95% CI, p < 0.001) and significantly improved disease-free survival (median, 12 months, 95% CI, vs 9 months, 95% CI, p = 0.01). CONCLUSIONS Achievement of TOO as defined by consensus statement is associated with improved survival.
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Affiliation(s)
- Nitzan Zohar
- From the Jefferson Pancreas, Biliary and Related Cancer Center, Jefferson Health, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
- Department of General and Oncological Surgery-Surgery C, Sheba Medical Center, Tel-Hashomer, Israel (Zohar, Benvenisti, Elbaz, Assaf, Mor)
| | - Avinoam Nevler
- From the Jefferson Pancreas, Biliary and Related Cancer Center, Jefferson Health, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
| | | | - Charles J Yeo
- From the Jefferson Pancreas, Biliary and Related Cancer Center, Jefferson Health, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
| | - Haggai Benvenisti
- Department of General and Oncological Surgery-Surgery C, Sheba Medical Center, Tel-Hashomer, Israel (Zohar, Benvenisti, Elbaz, Assaf, Mor)
| | - Nadav Elbaz
- Department of General and Oncological Surgery-Surgery C, Sheba Medical Center, Tel-Hashomer, Israel (Zohar, Benvenisti, Elbaz, Assaf, Mor)
| | - Dan Assaf
- Department of General and Oncological Surgery-Surgery C, Sheba Medical Center, Tel-Hashomer, Israel (Zohar, Benvenisti, Elbaz, Assaf, Mor)
| | - Eyal Mor
- Department of General and Oncological Surgery-Surgery C, Sheba Medical Center, Tel-Hashomer, Israel (Zohar, Benvenisti, Elbaz, Assaf, Mor)
| | - Wilbur B Bowne
- From the Jefferson Pancreas, Biliary and Related Cancer Center, Jefferson Health, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA (Zohar, Nevler, Yeo, Bowne)
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Florissi I, Radomski SN, Shou B, Cloyd JM, Kim A, Grotz T, Fournier K, Baumgartner JM, Lambert L, Abbott DE, Schwartz P, Staley CA, Clarke C, Dineen S, Patel SH, Wilson GC, Raoof M, Johnston FM, Greer JB. Weekend Discharge Is Not Associated With Increased Readmission After Hyperthermic Intraperitoneal Chemotherapy. J Surg Res 2024; 293:403-412. [PMID: 37806228 DOI: 10.1016/j.jss.2023.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/18/2023] [Accepted: 08/26/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION We explored the association between weekend discharge and 30- and 90-d readmission rates in patients undergoing hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal carcinomatosis. METHODS The US HIPEC Collaborative database, comprised of a longitudinal cohort of patients undergoing CRS/HIPEC for peritoneal carcinomatosis at twelve academic institutions between 2000 and 2017, was queried for date of discharge information. Patients were retrospectively divided into weekday and weekend/holiday discharge groups. Patients <18 y old, lacking day of discharge information, or who experienced intraoperative/in-hospital mortality were excluded. Comparisons were made between patients discharged on a weekday versus those discharged on a weekend or major holiday. RESULTS 1415 patients met inclusion criteria for the study: 1108 (78%) patients with a weekday discharge and 308 (22%) with a weekend/holiday discharge. Median age at time of surgery was 55 y (Interquartile Range: 46-63); 59% (n = 841) patients were female, 25% (n = 328) of patients had high volume disease (defined as a peritoneal cancer index >20 intraoperatively), and 92% (n = 1210) of patients had a complete cytoreduction (defined as a completeness of cytoreduction score of 0 or 1). Overall, 15% (n = 218) of patients were readmitted within 30 d and 19% (n = 265) within 90 d. In a linear mixed effects model, weekend discharge was not associated with higher 30- or 90-d readmissions (P = 0.291, P = 0.743). CONCLUSIONS Weekend discharges are safe following CRS/HIPEC. Length of stay initiatives should focus on discharging the patient when medically ready, rather than avoiding weekend discharge out of an abundance of caution.
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Affiliation(s)
- Isabella Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benjamin Shou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Travis Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, La Jolla, California
| | - Laura Lambert
- Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Patrick Schwartz
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sean Dineen
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, Florida
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mustafa Raoof
- City of Hope National Medical Center, Department of Surgery, Duarte, California
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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5
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Winicki NM, Radomski SN, Florissi IS, Cloyd JM, Gutta G, Grotz TE, Scally CP, Fournier KF, Dineen SP, Powers BD, Veerapong J, Baumgartner JM, Clarke CN, Kothari AN, Maduekwe UN, Patel SH, Wilson GC, Schwartz P, Varley PR, Raoof M, Lee B, Malik I, Johnston FM, Greer JB. Neighborhood-Level Socioeconomic Disadvantage Predicts Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Malignancy. Ann Surg Oncol 2023; 30:7840-7847. [PMID: 37620532 PMCID: PMC10592201 DOI: 10.1245/s10434-023-14074-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) improves survival in select patients with peritoneal metastases (PM), but the impact of social determinants of health on CRS/HIPEC outcomes remains unclear. PATIENTS AND METHODS A retrospective review was conducted of a multi-institutional database of patients with PM who underwent CRS/HIPEC in the USA between 2000 and 2017. The area deprivation index (ADI) was linked to the patient's residential address. Patients were categorized as living in low (1-49) or high (50-100) ADI residences, with increasing scores indicating higher socioeconomic disadvantage. The primary outcome was overall survival (OS). Secondary outcomes included perioperative complications, hospital/intensive care unit (ICU) length of stay (LOS), and disease-free survival (DFS). RESULTS Among 1675 patients 1061 (63.3%) resided in low ADI areas and 614 (36.7%) high ADI areas. Appendiceal tumors (n = 1102, 65.8%) and colon cancer (n = 322, 19.2%) were the most common histologies. On multivariate analysis, high ADI was not associated with increased perioperative complications, hospital/ICU LOS, or DFS. High ADI was associated with worse OS (median not reached versus 49 months; 5 year OS 61.0% versus 28.2%, P < 0.0001). On multivariate Cox-regression analysis, high ADI (HR, 2.26; 95% CI 1.13-4.50; P < 0.001), cancer recurrence (HR, 2.26; 95% CI 1.61-3.20; P < 0.0001), increases in peritoneal carcinomatosis index (HR, 1.03; 95% CI 1.01-1.05; P < 0.001), and incomplete cytoreduction (HR, 4.48; 95% CI 3.01-6.53; P < 0.0001) were associated with worse OS. CONCLUSIONS Even after controlling for cancer-specific variables, adverse outcomes persisted in association with neighborhood-level socioeconomic disadvantage. The individual and structural-level factors leading to these cancer disparities warrant further investigation to improve outcomes for all patients with peritoneal malignancies.
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Affiliation(s)
- Nolan M Winicki
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shannon N Radomski
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Isabella S Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Goutam Gutta
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Christopher P Scally
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keith F Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Benjamin D Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jula Veerapong
- Department of Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Joel M Baumgartner
- Department of Surgery, UC San Diego School of Medicine, La Jolla, CA, USA
| | - Callisia N Clarke
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anai N Kothari
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ugwuji N Maduekwe
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Patrick Schwartz
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Patrick R Varley
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Mustafa Raoof
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Byrne Lee
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Ibrahim Malik
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Gastrointestinal Surgical Oncology, Peritoneal Surface Malignancy Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Algera MD, Slangen BFM, van Driel WJ, Wouters MWJM, Kruitwagen RFPM. Textbook outcome as a composite outcome measure to compare hospital performances regarding cytoreductive surgery for ovarian cancer: A nationwide population-based study. Gynecol Oncol 2023; 174:89-97. [PMID: 37167897 DOI: 10.1016/j.ygyno.2023.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Textbook outcome (TO) is a composite outcome measure used in surgical oncology to compare hospital outcomes using multiple quality indicators. This study aimed to develop TO as an outcome measure to assess healthcare quality for patients undergoing cytoreductive surgery (CRS) for advanced-stage ovarian cancer. METHODS This population-based study included all CRS for FIGO IIIC-IVB primary ovarian cancer registered in the Netherlands between 2017 and 2020. The primary outcome was TO, defined as a complete CRS, combined with the absence of 30-day mortality, severe complications, and prolonged length of admission (≥ten days). Delayed start of adjuvant chemotherapy (≥six weeks) was not included in TO because of missing data. Logistic regressions were used to assess the association of case-mix factors with TO. Hospital variation was displayed using funnel plots. RESULTS A total of 1909 CRS were included, of which 1434 were interval CRS and 475 were primary CRS. TO was achieved in 54% of the interval CRS cohort and 47% of the primary CRS cohort. Macroscopic residual disease after CRS was the most important factor for not achieving TO. Age ≥ 70 was associated with lower TO rates in multivariable logistic regressions. TO rates ranged from 40% to 69% between hospitals in the interval CRS cohort and 22% to 100% in the primary CRS cohort. In both analyses, one hospital had significantly lower TO rates (different hospitals). Case-mix adjustment significantly affected TO rates in the primary CRS analysis. CONCLUSIONS TO is a suitable composite outcome measure to detect hospital variation in healthcare quality for patients with advanced-stage ovarian cancer undergoing CRS. Case-mix adjustment improves the accuracy of the hospital comparison.
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Affiliation(s)
- M D Algera
- Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands; Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands.
| | - B F M Slangen
- Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands
| | - W J van Driel
- Center for Gynecological Oncology Amsterdam, Netherlands Cancer Institute, Department of Gynecology, Amsterdam, the Netherlands
| | - M W J M Wouters
- Dutch Institute for Clinical Auditing (DICA), Scientific Bureau, Leiden, the Netherlands; Netherlands Cancer Institute, Department of Surgical Oncology, Amsterdam, the Netherlands; Leiden University Medical Center, Department of Biomedical Data Sciences, Leiden, the Netherlands
| | - R F P M Kruitwagen
- Maastricht University Medical Center (MUMC+), Department of Obstetrics and Gynecology, Maastricht, the Netherlands; GROW- School for Oncology and Reproduction, Maastricht, the Netherlands
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Kubi B, Nudotor R, Fackche N, Rowe J, Cloyd JM, Ahmed A, Grotz TE, Fournier K, Dineen S, Veerapong J, Baumgartner JM, Clarke C, Patel SH, Dhar V, Lambert L, Abbott DE, Pokrzywa C, Raoof M, Lee B, Zaidi MY, Maithel SK, Johnston FM, Greer JB. Influence of insurance status on the postoperative outcomes of cytoreductive surgery and HIPEC. J Surg Oncol 2023; 127:706-715. [PMID: 36468401 DOI: 10.1002/jso.27147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/19/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is increasingly performed for peritoneal surface malignancies but remains associated with significant morbidity. Scant research is available regarding the impact of insurance status on postoperative outcomes. METHODS Patients undergoing CRS/HIPEC between 2000 and 2017 at 12 participating sites in the US HIPEC Collaborative were identified. Univariate and multivariate analyses were used to compare the baseline characteristics, operative variables, and postoperative outcomes of patients with government, private, or no insurance. RESULTS Among 2268 patients, 699 (30.8%) had government insurance, 1453 (64.0%) had private, and 116 (5.1%) were uninsured. Patients with government insurance were older, more likely to be non-white, and comorbid (p < 0.05). Patients with government (OR: 2.25, CI: 1.50-3.36, p < 0.001) and private (OR: 1.69, CI: 1.15-2.49, p = 0.008) insurance had an increased risk of complications on univariate analysis. There was no independent relationship on multivariate analysis. An American Society of Anesthesiologists score of 3 or 4, peritoneal carcinomatosis index score >15, completeness of cytoreduction score >1, and nonhome discharge were factors independently associated with a postoperative complication. CONCLUSION While there were differences in postoperative outcomes between the three insurance groups on univariate analysis, there was no independent association between insurance status and postoperative complications after CRS/HIPEC.
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Affiliation(s)
- Boateng Kubi
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Richard Nudotor
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Nadege Fackche
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Julian Rowe
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmed Ahmed
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean Dineen
- Department of Gastrointestinal Oncology and Oncologic Sciences, Moffitt Cancer Center, Morsani College of Medicine, Tampa, Florida, USA
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego, California, USA
| | - Joel M Baumgartner
- Department of Surgery, Division of Surgical Oncology, University of California, San Diego, California, USA
| | - Callisia Clarke
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Vikrom Dhar
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Laura Lambert
- Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin, USA
| | - Courtney Pokrzywa
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin, USA
| | - Mustafa Raoof
- Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Byrne Lee
- Department of Surgery, Division of Surgical Oncology, City of Hope National Medical Center, Duarte, California, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan B Greer
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
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8
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Beal EW, Srinivas S, Shen C, Kim A, Johnston FM, Greer J, Abbott DE, Pokrzywa C, Raoof M, Grotz TE, Leiting JL, Fournier K, Dineen S, Powers B, Veerapong J, Kothari A, Maduekew U, Maithel S, Wilson GC, Patel SH, Lambert L, Abdel-Misih S, Cloyd JM. Conditional Survival Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies: An Analysis from the US HIPEC Collaborative. Ann Surg Oncol 2023; 30:1840-1849. [PMID: 36310315 DOI: 10.1245/s10434-022-12753-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 10/19/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The long-term prognosis of patients who undergo cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal surface malignancies (PSM) varies considerably on the basis of histological and operative factors. While overall survival (OS) estimates are used to inform adjuvant therapy and surveillance strategies, conditional survival may provide more clinically relevant estimates of prognosis by accounting for disease-free time elapsed. PATIENTS AND METHODS All patients from 12 academic institutions who underwent CRS ± HIPEC for PSM from 2000 to 2017 were retrospectively analyzed. OS and disease-free survival (DFS) rates were calculated using the Kaplan-Meier method while conditional overall (COS) and conditional disease-free survival (CDFS) rates were calculated at 1, 2, or 3 years from surgery for different tumor histologies. RESULTS Overall, 1610 patients underwent CRS ± HIPEC. Among patients with benign appendiceal mucinous tumors (N = 460), 5-year OS and COS at 3 years were 92.1% and 96.3% (Δ4.2%), respectively. For patients with well-differentiated appendiceal cancers (N = 400), 5-year OS and COS at 3 years were 76.3% and 88.3% (Δ12.0%), respectively. For patients with high-grade appendiceal cancers (N = 258), 5-year OS and COS at 3 years were 43.8% and 75.4% (Δ31.6%), respectively. For patients with colorectal cancers (N = 362), 5-year OS and COS at 3 years were 31.8% and 67.3% (Δ35.5%), respectively. For patients with peritoneal mesothelioma (N = 130), 5-year OS and COS at 3 years were 67.6% and 89.7% (Δ22.1%), respectively. Similar trends were observed for DFS/CDFS. CONCLUSION The conditional survival of patients undergoing CRS ± HIPEC for PSM is associated with tumor histology. COS and CDFS provide a more accurate, dynamic estimate of survival than OS and DFS, especially for patients with more aggressive histologies.
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Affiliation(s)
- Eliza W Beal
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Shruthi Srinivas
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Chengli Shen
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Alex Kim
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Anai Kothari
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | | - Laura Lambert
- University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Sherif Abdel-Misih
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
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Gearing PF, Hawke JA, Mohan H, Heriot AG, Khan A, Beaumont A, Laing E, Waters PS. Perioperative nutritional assessment and interventions in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): A systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:902-917. [PMID: 36872111 DOI: 10.1016/j.ejso.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/13/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Peritoneal carcinomatosis is a catabolic state and cytoreductive surgery (CRS) is a high morbidity operation. Optimising perioperative nutrition is crucial to improve outcomes. This systematic review sought to examine literature describing clinical outcomes related to preoperative nutrition status and nutrition interventions in patients undergoing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS A systematic review was registered with PROSPERO (300326). A search of eight electronic databases was undertaken on 8th May 2022 and reported according to the PRISMA statement. Studies reporting nutrition status through use of screening and assessment tools, nutrition interventions or nutrition-related clinical outcomes for patients undergoing CRS with HIPEC were included. RESULTS Of 276 screened studies, 25 studies were included for review. Commonly used nutrition assessment tools for CRS-HIPEC patients included Subjective Global Assessment (SGA), sarcopenia assessment with computed tomography, preoperative albumin, and body mass index (BMI). Three retrospective studies compared SGA with postoperative outcomes. Malnourished patients were more likely to have postoperative infectious complications (p = 0.042 SGA-B, p = 0.025 SGA-C). Malnutrition was significantly associated with increased hospital length of stay (LOS) in two studies (p = 0.006, p = 0.02), and with overall survival in another study (p = 0.006). Eight studies analysing preoperative albumin levels reported conflicting associations with postoperative outcomes. BMI in five studies was not associated with morbidity. One study did not support routine nasogastric tube (NGT) feeding. CONCLUSIONS Preoperative nutritional assessment tools, including SGA and objective sarcopaenia measures, have a role in predicting nutritional status for CRS-HIPEC patients. Optimisation of nutrition is important for preventing complications.
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Affiliation(s)
- Peter F Gearing
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
| | - Justin A Hawke
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Helen Mohan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Ayman Khan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Anna Beaumont
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Erin Laing
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Peadar S Waters
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia; Department of Surgery, Cork University Hospital, Wilton Road, Cork, Ireland
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10
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Textbook Outcome of Laparoscopic Microwave Ablation for Hepatocellular Carcinoma. Cancers (Basel) 2023; 15:cancers15020436. [PMID: 36672385 PMCID: PMC9856576 DOI: 10.3390/cancers15020436] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/28/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023] Open
Abstract
In the context of spreading interest in textbook outcome (TO) evaluation in different fields, we aimed to investigate an uncharted procedure, that is, laparoscopic microwave ablation (MWA) for hepatocellular carcinoma (HCC). Absence of post-MWA complications, a hospital stay of three days, no mortality nor readmission within 30 days, and complete response of the target lesion at post-MWA CT scan defined TO achievement. Patients treated between January 2014 and March 2021 were retrospectively reviewed, and of the 521 patients eligible for the study, 337 (64.7%) fulfilled all the quality indicators to achieve the TO. The absence of complications was the main limiting factor for accomplishing TO. At multivariable analysis, Child-Pugh B cirrhosis, age of more than 70 years old, three nodules, and MELD score ≥ 15 were associated with decreased probabilities of TO achievement. A score based on these factors was derived from multivariable analysis, and patients were divided into three risk groups for TO achievement. At survival analysis, overall survival (OS) was significantly (p = 0.001) higher in patients who achieved TO than those who did not. Moreover, OS evaluation in the three risk groups showed a trend coherent with TO achievement probability. The present study, having assessed the first TO for laparoscopic MWA for HCC, encourages further broader consensus on its definition and, on its basis, on the development of clinically relevant tools for managing treatment allocation.
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11
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Complications and Mortality Rate of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: Italian Peritoneal Surface Malignancies Oncoteam Results Analysis. Cancers (Basel) 2022; 14:cancers14235824. [PMID: 36497306 PMCID: PMC9741330 DOI: 10.3390/cancers14235824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy may significantly improve survival for selected patients with peritoneal surface malignancies, but it has always been criticized due to the high incidence of postoperative morbidity and mortality. METHODS Data were collected from nine Italian centers with peritoneal surface malignancies expertise within a collaborative group of the Italian Society of Surgical Oncology. Complications and mortality rates were recorded, and multivariate Cox analysis was used to identify risk factors. RESULTS The study included 2576 patients. The procedure was mostly performed for ovarian (27.4%) and colon cancer (22.4%). The median peritoneal cancer index was 13. Overall postoperative morbidity and mortality rates were 34% and 1.6%. A total of 232 (9%) patients required surgical reoperation. Multivariate regression logistic analysis identified the type of perfusion (p ≤ 0.0001), body mass index (p ≤ 0.0001), number of resections (p ≤ 0.0001) and colorectal resections (p ≤ 0.0001) as the strongest predictors of complications, whereas the number of resections (p ≤ 0.0001) and age (p = 0.01) were the strongest predictors of mortality. CONCLUSIONS Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is a valuable option of treatment for selected patients with peritoneal carcinomatosis providing low postoperative morbidity and mortality rates, if performed in high-volume specialized centers.
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12
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Beal EW, Dalmacy D, Paro A, Hyer JM, Cloyd J, Dillhoff M, Ejaz A, Pawlik TM. Comparing Minimally Invasive and Open Pancreaticoduodenectomy for the Treatment of Pancreatic Cancer: a Win Ratio Analysis. J Gastrointest Surg 2022; 26:1697-1704. [PMID: 35705834 DOI: 10.1007/s11605-022-05380-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/03/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Despite its rising adoption, the use of minimally invasive (MIS) pancreaticoduodenectomy (PD) in the treatment of pancreatic cancer remains controversial. We sought to compare MIS and open PD for pancreatic cancer resection in terms of short-term, long-term, and oncologic outcomes using the win ratio, a novel statistical approach. METHODS Patients undergoing PD for pancreatic adenocarcinoma 2010-2016 were identified from the National Cancer Database (NCDB). Patients were paired based on age, sex, race, tumor size, Charlson-Deyo score, and receipt of neoadjuvant chemotherapy. The win ratio was calculated based on 30-day and 3-year mortality, receipt of adjuvant chemotherapy, surgical margin status, examination of at least 11 lymph nodes, extended length of stay, and 30-day readmission. RESULTS Among 18,936 patients, median age was 67 (IQR: 60-74); most patients had stage II disease at diagnosis (n = 16,530, 87.3%) and tumor size ≥ 2 cm (n = 15,880, 83.9%). The majority of patients underwent open PD (n = 16,409, 86.7%) versus MIS PD (n = 2527, 13.3%). For every matched patient-patient pair, the odds of the patient undergoing MIS PD "winning" were 1.14 (95%CI 1.13-1.15) higher versus open PD. The benefits of MIS PD were most pronounced among patients with tumor size < 2 cm (WR 1.21, 95%CI 1.13-1.30 versus ≥ 2 cm, WR 1.13, 95%CI 1.12-1.14) and patients who received neoadjuvant chemotherapy prior to resection (WR 1.28, 95%CI 1.23-1.32 versus no neoadjuvant chemotherapy, WR 1.13, 95%CI 1.11-1.14). CONCLUSIONS MIS PD may be preferable to open PD based on a hierarchical composite outcome that considered short-term, long-term, and oncologic outcomes.
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Affiliation(s)
- Eliza W Beal
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Djhenne Dalmacy
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Alessandro Paro
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Cancer Hospital and Solove Research Institute, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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13
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Beal EW, Chen JC, Kim A, Johnston FM, Abbott DE, Raoof M, Grotz TE, Fournier K, Dineen S, Veerapong J, Clarke C, Staley C, Patel SH, Lambert L, Cloyd JM. Is CRS-HIPEC Still Indicated in Patients With Extraperitoneal Disease? J Surg Res 2022; 277:269-278. [PMID: 35525209 DOI: 10.1016/j.jss.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/28/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The role of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with extraperitoneal disease (EPD) is controversial. METHODS Among patients with peritoneal metastases from appendiceal cancer (AC) and colorectal cancer (CRC) who underwent CRS-HIPEC, those with EPD (liver, lung, or retroperitoneal lymph nodes [RP LN]) were retrospectively compared to those without EPD. Overall (OS) and recurrence-free survival (RFS) analyses were performed before/after propensity score matching (PSM). RESULTS Among 1341 patients with AC (64%) or CRC (36%) who underwent CRS ± HIPEC, 134 (10%) had EPD whereas 1207 (90%) did not. EPD was located in the lungs (47%), RP LN (28%), liver (18%), or multiple (6%). Patients with EPD experienced worse median OS (34 versus 63 mo; P = 0.002) and RFS (12 versus 19 mo; P < 0.001). On a multivariable analysis, EPD was associated with worse RFS (P = 0.003), but not OS (P = 0.071). After PSM, the association of EPD with OS (P = 0.204) and RFS (P = 0.056) was no longer significant. In the multivariable analysis of the PSM cohort, EPD was not associated with OS (P = 0.157) or RFS (P = 0.110). CONCLUSIONS The findings of this large retrospective multi-institutional study suggest that EPD alone, while a negative prognostic indicator, should not be considered an absolute contraindication to CRS ± HIPEC for otherwise well-selected patients with peritoneal surface malignancies. Further research is needed to delineate whether location of EPD influences OS and RFS following CRS-HIPEC.
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Affiliation(s)
- Eliza W Beal
- The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio
| | - J C Chen
- The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio
| | - Alex Kim
- The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio
| | | | | | | | | | | | | | - Jula Veerapong
- University of California San Diego, San Diego, California
| | | | | | | | - Laura Lambert
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Jordan M Cloyd
- The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio.
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14
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Deng H, Eftekhari Z, Carlin C, Veerapong J, Fournier KF, Johnston FM, Dineen SP, Powers BD, Hendrix R, Lambert LA, Abbott DE, Vande Walle K, Grotz TE, Patel SH, Clarke CN, Staley CA, Abdel-Misih S, Cloyd JM, Lee B, Fong Y, Raoof M. Development and Validation of an Explainable Machine Learning Model for Major Complications After Cytoreductive Surgery. JAMA Netw Open 2022; 5:e2212930. [PMID: 35612856 PMCID: PMC9133947 DOI: 10.1001/jamanetworkopen.2022.12930] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/31/2022] [Indexed: 11/16/2022] Open
Abstract
Importance Cytoreductive surgery (CRS) is one of the most complex operations in surgical oncology with significant morbidity, and improved risk prediction tools are critically needed. Machine learning models can potentially overcome the limitations of traditional multiple logistic regression (MLR) models and provide accurate risk estimates. Objective To develop and validate an explainable machine learning model for predicting major postoperative complications in patients undergoing CRS. Design, Setting, and Participants This prognostic study used patient data from tertiary care hospitals with expertise in CRS included in the US Hyperthermic Intraperitoneal Chemotherapy Collaborative Database between 1998 and 2018. Information from 147 variables was extracted to predict the risk of a major complication. An ensemble-based machine learning (gradient-boosting) model was optimized on 80% of the sample with subsequent validation on a 20% holdout data set. The machine learning model was compared with traditional MLR models. The artificial intelligence SHAP (Shapley additive explanations) method was used for interpretation of patient- and cohort-level risk estimates and interactions to define novel surgical risk phenotypes. Data were analyzed between November 2019 and August 2021. Exposures Cytoreductive surgery. Main Outcomes and Measures Area under the receiver operating characteristics (AUROC); area under the precision recall curve (AUPRC). Results Data from a total 2372 patients were included in model development (mean age, 55 years [range, 11-95 years]; 1366 [57.6%] women). The optimized machine learning model achieved high discrimination (AUROC: mean cross-validation, 0.75 [range, 0.73-0.81]; test, 0.74) and precision (AUPRC: mean cross-validation, 0.50 [range, 0.46-0.58]; test, 0.42). Compared with the optimized machine learning model, the published MLR model performed worse (test AUROC and AUPRC: 0.54 and 0.18, respectively). Higher volume of estimated blood loss, having pelvic peritonectomy, and longer operative time were the top 3 contributors to the high likelihood of major complications. SHAP dependence plots demonstrated insightful nonlinear interactive associations between predictors and major complications. For instance, high estimated blood loss (ie, above 500 mL) was only detrimental when operative time exceeded 9 hours. Unsupervised clustering of patients based on similarity of sources of risk allowed identification of 6 distinct surgical risk phenotypes. Conclusions and Relevance In this prognostic study using data from patients undergoing CRS, an optimized machine learning model demonstrated a superior ability to predict individual- and cohort-level risk of major complications vs traditional methods. Using the SHAP method, 6 distinct surgical phenotypes were identified based on sources of risk of major complications.
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Affiliation(s)
- Huiyu Deng
- City of Hope National Medical Center, Duarte, California
| | | | - Cameron Carlin
- City of Hope National Medical Center, Duarte, California
| | | | | | | | | | | | - Ryan Hendrix
- University of Massachusetts, Worcester, Massachusetts
| | | | | | | | | | | | | | | | | | | | - Byrne Lee
- Stanford University, Stanford, California
| | - Yuman Fong
- City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- City of Hope National Medical Center, Duarte, California
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15
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Dal Cero M, Román M, Grande L, Yarnoz C, Estremiana F, Gantxegi A, Codony C, Gobbini Y, Garsot E, Momblan D, González-Duaigües M, Luna A, Pérez N, Aldeano A, Fernández S, Olona C, Hermoso J, Pulido L, Sánchez-Cano JJ, Güell M, Salazar D, Gimeno M, Pera M. Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis. Eur J Surg Oncol 2021; 48:768-775. [PMID: 34753620 DOI: 10.1016/j.ejso.2021.10.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/20/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The concept of textbook outcome (TO) has been proposed for analyzing quality of surgical care. This study assessed the incidence of TO among patients undergoing curative gastric cancer resection, predictors for TO achievement, and the association of TO with survival. METHOD All patients with gastric and gastroesophageal junction cancers undergoing curative gastrectomy between January 2014-December 2017 were identified from a population-based database (Spanish EURECCA Registry). TO included: macroscopically complete resection at the time of operation, R0 resection, ≥15 lymph nodes removed and examined, no serious postoperative complications (Clavien-Dindo ≥II), no re-intervention, hospital stay ≤14 days, no 30-day readmissions and no 90-day mortality. Logistic regression was used to assess the adjusted achievement of TO. Cox survival regression was used to compare conditional adjusted survival across groups. RESULTS In total, 1293 patients were included, and TO was achieved in 541 patients (41.1%). Among the criteria, "macroscopically complete resection" had the highest compliance (96.5%) while "no serious complications" had the lowest compliance (63.7%). Age (OR 0.53 for the 65-74 years and OR 0.34 for the ≥75 years age group), Charlson comorbidity index ≥3 (OR 0.53, 95%CI 0.34-0.82), neoadjuvant chemoradiotherapy (OR 0.24, 95%CI 0.08-0.70), multivisceral resection (OR 0.55, 95%CI 0.33-0.91), and surgery performed in a community hospital (OR 0.65, CI95% 0.46-0.91) were independently associated with not achieving TO. TO was independently associated with conditional survival (HR 0.67, 95%CI 0.55-0.83). CONCLUSION TO was achieved in 41.1% of patients who underwent gastric cancer resection with curative intent and was associated with longer survival.
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Affiliation(s)
- Mariagiulia Dal Cero
- Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Hospital del Mar Medical Research Institute (IMIM). Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Román
- Department of Epidemiology and Evaluation, Hospital Universitario del Mar, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Luis Grande
- Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Hospital del Mar Medical Research Institute (IMIM). Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Concepción Yarnoz
- Department of Surgery, Hospital Universitario de Navarra, Pamplona, Spain
| | - Fernando Estremiana
- Department of Surgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Amaia Gantxegi
- Department of Surgery, Hospital Vall d'Hebron, Barcelona, Spain
| | - Clara Codony
- Department of Surgery, Hospital Universitari Josep Trueta, Girona, Spain
| | - Yanina Gobbini
- Department of Surgery, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despí, Barcelona, Spain
| | - Elisenda Garsot
- Department of Surgery, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Dulce Momblan
- Department of Surgery, Hospital Clinic, Barcelona, Spain
| | | | - Alexis Luna
- Department of Surgery, Hospital Universitari Parc Taulí de Sabadell, Sabadell, Barcelona, Spain
| | - Noelia Pérez
- Department of Surgery, Hospital Universitari Mútua Terrassa, Terrassa, Barcelona, Spain
| | - Aurora Aldeano
- Department of Surgery, Hospital General de Granollers, Granollers, Barcelona, Spain
| | | | - Carles Olona
- Department of Surgery, Hospital Universitari de Tarragona, Joan XXIII, Tarragona, Spain
| | - Judit Hermoso
- Department of Surgery, Hospital Universitari de Vic, Vic, Barcelona, Spain
| | - Laura Pulido
- Department of Surgery, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Barcelona, Spain
| | | | - Mercè Güell
- Department of Surgery, Althaia Xarxa Assistencial i Universitária de Manresa, Manresa, Spain
| | - David Salazar
- Department of Surgery, Hospital Universitari de Igualada, Igualada, Barcelona, Spain
| | - Marta Gimeno
- Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Hospital del Mar Medical Research Institute (IMIM). Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Pera
- Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Hospital del Mar Medical Research Institute (IMIM). Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Aquina CT, Hamad A, Becerra AZ, Cloyd JM, Tsung A, Pawlik TM, Ejaz A. Is Textbook Oncologic Outcome a Valid Hospital-Quality Metric after High-Risk Surgical Oncology Procedures? Ann Surg Oncol 2021; 28:8028-8045. [PMID: 34392460 DOI: 10.1245/s10434-021-10478-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND "Textbook oncologic outcome" (TOO) is a composite quality measure representing the "ideal" outcome for patients undergoing cancer surgery. This study sought to assess the validity of TOO as a metric to evaluate hospital quality. METHODS Patients who underwent curative-intent resection of gastric, pancreatic, colon, rectal, lung, esophageal, bladder, or ovarian cancer were identified in the National Cancer Database (2006-2017). Cancer site-specific TOO was defined as adequate lymph node yield, R0 resection, non-length-of-stay outlier, no hospital readmission, and receipt of guideline-concordant chemotherapy and/or radiation. Mixed-effects analyses estimated the adjusted TOO rate for each hospital stratified by cancer site. The association between hospital adjusted TOO rates and 5-year overall survival was assessed using mixed-effects Cox proportional hazards analyses. RESULTS Among 852,988 cancer resections, the TOO rate varied across cancer sites as follows: stomach (31.8%), pancreas (25%), colon (66.9%), rectum (33.6%), lung (35.1%), esophagus (31.2%), bladder (43%), and ovary (44.7%). After characterization of adjusted hospital TOO rates into quintiles, an incremental improvement in overall survival was observed, with higher adjusted TOO rates. Similarly, with the adjusted hospital TOO rate treated as a continuous variable, there was a significant 4% to 12% improvement in overall survival for every 10% increase in the adjusted hospital TOO rate for gastric (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.85-0.91), pancreatic (HR, 0.90; 95% CI, 0.88-0.93), colon (0.93; 95% CI, 0.91-0.94), rectal (HR, 0.90; 95% CI, 0.87-0.93), lung (HR, 0.96; 95% CI, 0.95-0.97), esophageal (HR, 0.93; 95% CI, 0.90-0.95), bladder (HR, 0.94; 95% CI, 0.91-0.97), and ovarian (HR, 0.96; 95% CI, 0.94-0.98) cancer. CONCLUSIONS A direct association exists between adjusted hospital TOO rates and survival after high-risk cancer procedures. As a valid hospital metric, TOO can be used to compare the overall quality of cancer care across hospitals.
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Affiliation(s)
- Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
| | - Ahmad Hamad
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
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